Providentia

Will Pellagra Make a Comeback?

Pellagra is a vitamin deficiency disease that is often reported in Africa, Central America, and South-east Asia. Caused by tryptophan and niacin-poor diets, it has also been identified in marginalized individuals in industrial societies (especially homeless, chronic alcoholic, and psychiatric patients who refuse food). Symptoms of pellagra include light sensitivity, dementia, diarrhea, and dermatitis. In advanced cases, pellagra can lead to psychotic delusions. Left untreated, pellagra cases die after several years without proper nutrition.

While first identified in Spain in the 18th century, it received its name from an epidemic in Italy ("pelle agra" means bitter skin in Italian). Pellagra was epidemic in parts of the US in the early 1900s before the nutritional basis for the disease was identified and niacin supplements made treatment possible. While easy to diagnose and treat, physicians often miss vital clues, especially in industrialized societies where pellagra is less likely to be encountered. Even in non-industrialized countries, improved standard of living and greater diversity in dietary sources have made pellagra less common.

But an article published a few years back in the American Journal of Therapeutics discussed the possible resurgence of pellagra in HIV patients and anorexia nervosa patients who neglect proper nutrition. The authors also reviewed a case f pellagra identified through the warning triad of "dermatosis, diarrhea, and dementia" and properly treated.   In the twelve years since that particular study was published,   there has been an upswing in new pellagra cases which have been largely linked to the popularity of certain restricted diets such as extreme veganism.   A 2021 article reviews a case of pellagra involving a strict vegan who was diagnosed and treated for pellagra and warns health professionals of the need to stay aware of how easily such a patient might be misdiagnosed.     

For all that it is considered extinct in affluent countries, pellagra has never completely gone away.    Something to think about if you are considering a new fad diet...

The Heart of a Soldier

The outbreak of the American Civil War in 1861 meant new challenges for the medical doctors treating the wounded on both sides of the conflict.   But with these new challenges came timely new  developments to help diagnosis and treatment of injured soldiers.   This included morphine,  the hypodermic needle and the stethoscope. 

Being able to listen to a patient's heart meant a new appreciation of how the heart worked and, to some extent, how it didn't.    Though the heart was recognized primarily as a muscle that pumped blood, old notions about the heart being the centre of emotion and personality in humans had not been completely forgotten by the mid-19th century.   Physicians already recognized that strong emotion could affect heart activity but, rather than simply relying on patient description of how stress affected them, physicians could listen to the heart directly and draw their own conclusions.   Conflicting ideas of what a heart actually did came into play during the Civil War as doctors began monitoring the vital signs of soldiers under combat conditions.  It was through studying soldiers that three physicians independently described what would be known as the "Irritable Heart Syndrome" or  more simply as "Soldier's Heart."   

Early reports of Soldier's Heart began in 1862 following the first attempt of the Army of the Potomac to invade Virginia.   If the soldiers expected an easy victory, they quickly learned otherwise as Robert E. Lee's Confederate troops managed to beat them back and eventually forced a retreat.   The shock of this defeat was a major blow to Northern confidence and the high casualty rate, including wounded soldiers who were simply abandoned as the army withdrew, added to the number of dead.    With defeat after defeat at Antietam and Fredericksburg came more casualties and physicians began noting unusual symptoms among the soldiers being treated.

Along with battlefield injuries and diseases such as malaria, dysentery, and typhoid, army physicians also observed severe heart palpitations in the soldiers who had survived combat.  According to one physician, Alfred Stille, the soldiers themselves attributed the strange symptoms to the rigourous campaigning, including long marches with heavy backpacks.    Based on his own observations, Stille concluded that the palpitations were due to "a state of extreme exhaustion, especially when produced by prolonged and violent muscular effort."   Other physicians reported on the "cardiac muscular exhaustion" seen in soldiers and expanded on what Stille was observing.   Henry Hartshorne described what he was seeing as "soldier's heart exhaustion."  Specific symptoms included a rapid, feeble pulse rate,  an abnormally fast heart rate (even when the solder was at rest),  and breathing problems.     Hartshorne argued that the symptoms were caused by overexertion, lack of rest, and poor nutrition though he was careful to distinguish the new syndrome from ordinary nervous exhaustion.

The name most commonly associated with the irritable heart syndrome seen in soldiers was Jacob Mendes Da Costa who was the first physician to link the symptoms he was observing to psychological factors.   The condition he described is often called Da Costa's Syndrome in his honour.   Essentially, he regarded the condition he was seeing in patients as a "cardiac neurosis" since "the mass of cardiac disorder is not organic, but functional. And of these again a very large proportion belong to the group which I have designated 'irritable heart'"    Since there was no physical signs of actual heart disease involved, the symptoms themselves represented the condition he needed to treat.   Along with the heart symptoms, soldiers were also describing "jerking during sleep" ,  disturbed sleep, and nightmares.    While Da Costa was careful not to label the new syndrome as being a mental disorder, he did insist that the condition was not easily faked (even then, military authorities were wary of possible malingers).  He also acknowledged that the condition was being seen more frequently in soldiers as the war dragged on, however.   Treatment with conventional heart medications such as digitalis showed little real effect.

After the war ended,  Da Costa continued writing about the condition which he saw in civilian patients as well.   He maintained that the symptoms could be caused by any significant strain which, among other things, could mean emotional shock.   Many of the case histories he presented described how his syndrome could develop even in non-soldiers.   Based on his cases, Da Costa wrote:  

We can understand how even mental emotion, acting through the nervous system on the nerves of the heart, may produce real trouble, and how the worry of life, and strain on the feelings, when long kept up, may give rise to conditions which, in figurative language, we call “heart-weary,” and “heart-sick,” and which, not as a figure of speech, but in truth, may be the beginning of actual cardiac malady.

Da Costa also  suggested that irritable heart symptoms could be caused by anything that resulted in overexertion of the heart including sexual disorders, abuse of tea or coffee, irregularity or excess in eating or drinking or, "long matrimonial engagements."    In other words, virtually anything that caused nervous irritability could cause irritable heart syndrome.  For treatment, Da Costa recommended rest about all else though he also advocated medication (especially digitalis for the heart).     Despite the lack of real evidence that "irritable heart syndrome" actually involved heart disease,  Da Costa's based his ideas about the syndrome on patients becoming "heart-weary" due to chronic overexertion.  

Though Da Costa and his colleagues came close to realizing the role that traumatic stress could play on the body, they never quite managed to make that final connection.   According to Robert Kugelmann,  physicians such as Da Costa mainly focused on the role that overexertion and fatigue had on the heart since these were things they could observe directly.    Acknowledging the role of psychic factors that could only be inferred likely seemed a step backward.  Da Costa described the rigours of combat that soldiers faced as well as lack of sleep, poor nutrition,  and exposure to disease.   All of these were potential factors for irritable heart syndrome as far as he was concerned.    That soldiers were also constantly afraid was something he failed to mention in his writings.   Whether because he did not want irritable heart patients accused of cowardice or  simply refused to consider other factors besides overwork, Da Costa never wavered in regarding fatigue as the culprit.  

And fatigue was certainly a problem in 19th century medicine.   In an era before labour legislation or safety regulations, many workers were obliged to work long hours under unsafe conditions we nowadays see only in Third World factories.   That many of these workers also developed irritable heart symptoms seemed to prove Da Costa's hypothesis about overwork being the culprit.   There were also the inevitable racist comparisons with some ethnic groups deemed to be hardier and less vulnerable to irritable heart symptoms than others.   As Roberts Bartholow pointed out in an 1867 Sanitary Commission report on military health, soldiers of Anglo-Saxon descent were the most immune to fatigue.  For African-American soldiers, he regarded them as "less enduring than the white soldier; less active, vigilant, and enterprising, and more given to malingering. The Mulatto is feebler than the Negro."   As the very bottom of the heap were the Spanish-American soldiers coming from states such as New Mexico who were "cowardly, unreliable, and difficult to control, in consequence of a very mercurial temperament.”

As the memory of the Civil War faded and new wars arose, the Irritable Heart Syndrome gave way to later diagnoses including "shell shock" which became popular during World War I.    With each new case, physicians also recognized that it was not a heart syndrome at all.     As cardiologist James MacKenzie pointed out in 1916, such cases " were overwhelmingly non-cardiac, the most likely etiology being the strain and exhaustion of life in the trenches superimposed on some 'toxic influence' caused by infection."  Once again, physicians were extremely reluctant to attribute the symptoms they were seeing to psychological factors such as acute stress given the stigma attached to anything suggesting that soldiers lacked courage.   Though "shell shock" made its introduction as a diagnosis during World War I, it would not be until well after World War II that the devastating impact of posttraumatic stress on soldiers would be grudgingly recognized.

Even today, the true diagnosis of the Irritable Heart Disorder symptoms described by Da Costa and other physicians is likely impossible based on the limited information available.   Though Posttraumatic Stress Disorder (PTSD) remains the most popular explanation for what Da Costa was describing,  physical causes such as poor nutrition and infection cannot be ruled out either.   That the horrors of war take a terrible toll on soldiers and civilians caught in the crossfire seems obvious enough now. Recognizing that constant threat of death could lead to "legitimate" medical conditions rather than the type of symptoms associated with "cowardice" would take much longer.

Why Are Sexually Transmitted Diseases on the Rise in the United States?

According to figures released by the Centers for Disease Control and Prevention (CDC) late last year,  total number of  cases of syphilis, gonorrhea and chlamydia in the United States soared to a record high last year, including an alarming jump in the rate of newborn deaths caused by congenital syphilis. In the latest edition of the CDC's annual Sexually Transmitted Disease Surveillance Report, .more than 2.4 million syphilis, gonorrhea and chlamydia infections were reported in the United States in 2018 alone, an increase of more than 100,000 cases from the previous year.  

The most common sexually transmitted disease, chlamydia, accounted for 1.7 million of those cases, the highest number ever recorded in one year by the CDC.  Gonorrhea accounted for 500,000 cases, also the highest number reported since 1991.  As for primary and secondary syphilis, the total number of cases stands at 115,000, also the highest number since 1991.  

While all three of the most common sexually transmitted diseases can be successfully treated with antibiotics, the medical consequences of these diseases being left untreated can be devastating.  Not only are people with untreated STDs at risk for infecting others, but they are also vulnerable to a wide range of medical problems, including infertility, ectopic pregnancy, and increased HIV risk.   When allowed to proceed to its tertiary stage, syphilis can lead to severe neurological problems in older adults while congenital syphilis – syphilis passed from a mother to her baby during pregnancy – can result in miscarriage, stillbirth, newborn death, and severe lifelong physical and neurological problems.

To read more, check out my new Psychology Today blog post.

 

 

Are Insecure Attachment Styles Linked to Risky Sexual Behaviour?

Attachment theory provides a powerful framework for understanding individual differences affecting interpersonal relationships and a range of health behavior outcomes. However, no meta-analyses have yet to examine the relationship between adult attachment styles and risky sexual behaviors. A new meta-analysis published in the journal Health Psychology synthesizes the results of the association between adult attachment and risky sexual behaviors. Method: Keywords were searched via PsycINFO, Web of Science, and Google Scholar.  Researchers used comprehensive meta-analysis (CMA) 3.0 to systematically synthesize and analyze the 42 effect sizes from 16 studies (total N = 7,233). Results showed that attachment anxiety has a small effect on having multiple partners (Fisher’s Z = .09, 95% CI [0.021, 0.154]; I² = 80.4%) and engaging in condomless sex (Fisher’s Z = .09, 95% CI [.006, 0.175]; I² = 82.5%), whereas attachment avoidance has a small effect on having multiple partners (Fisher’s Z = .06, 95% CI [0.019, 0.109]; I² = 57.6%) but no effect on engaging in condomless sex (Fisher’s Z = .05, 95% CI [−0.024, 0.117]; I2 = 73.9%). Furthermore, average age of participants in a study (z = 3.31, β = .01, p = .001) and type of risk population (z = 3.03, β = .12, p = .002) were found to be significant moderators. In conclusions, insecure attachment styles are related to risky sexual behaviors and the correlation between attachment anxiety and having multiple partners is stronger as the average age of participant increases and when the study population is specifically an at-risk population. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

For the abstract

Why is PrEP Not Used More Often to Curb HIV?

HIV is a serious problem in the USA, particularly for men who have sex with men (MSM). A new means of HIV prevention, called pre-exposure prophylaxis (PrEP), has been shown to be highly effective. However, in spite of earning FDA approval, adoption of PrEP by MSM has been limited. A study published in the journal Health Communication examined the experiences of a sample of 38 MSM who have adopted PrEP, focusing on communication with healthcare providers and social networks. In-depth interviews were used to collect data. Findings revealed that stigmatization by healthcare providers as well as stigmatization by other MSM was a relatively common experience for participants. Additionally, participants described that a high level of health literacy, health advocacy, and communication skill were necessary to adopt PrEP. Given these findings, strategies are suggested for improving MSM’s healthcare and increasing rates of PrEP adoption. (PsycINFO Database Record (c) 2018 APA, all rights reserved)

For the abstract

Are We Facing a New HIV Epidemic?

The international AIDS conference to be held in Amsterdam on July 23-27 of this year is expected to be the largest conference of its kind in the world.  But along with hearing about new initiatives in HIV prevention and the real success of prevention and treatment programs to date, delegates will also be learning about a new and frightening danger  only beginning  to receive serious attention:  HIV drug resistance.  

While the rise of antibiotic resistant strains of most diseases thought to be virtually eradicated up to now has alarmed medical professionals worldwide, the spectacular success of programs aimed at making HIV/AIDS into a manageable disease has led to a false sense of security, at least in developed nations where anti-retroviral drugs (ARVs) are easily obtained.   

The massive rollout of ARVs in recent years has certainly saved millions of lives and allowed countless others to live symptom-free at the cost of less than a dollar a day in most cases.  Since 2003, HIV/AIDS deaths have declined by 40 percent worldwide and most countries in sub-Saharan Africa are reporting declines in the 25 to 50 percent range. 

But HIV continues to be the fastest mutating disease organism on the planet.  As a zoonotic virus (an animal virus that has jumped to humans), it has a mutation rate more than a million times greater than bacteria.   And when two different HIV strains infect the same cell, it provides an opportunity for these different RNA strands to merge and create new recombinant viruses.   This skyrocketing genetic diversity  allows for the rapid development of  drug resistance in the multiple HIV strains currently infecting humans .

This problem is also compounded by the difficulty providing an effective drug cocktail regimen in many developing nations where drugs are harder to obtain.  Though there are 28 different anti-retroviral drugs approved for human use in the United States alone, most of these aren't available in other parts of the world and patients who become resistant to those few available treatments often end up dying as their symptoms become terminal.   Also, the economic costs of ARV treatment often mean that patients may not take the full recommended regimen providing a greater opportunity for drug resistance to develop.

In a bleak report released in June, 2017, the World Health Organization (WHO) indicated that 30 percent of people with HIV failed ARV treatment after one year in countries such as Cameroon.  Cases of acquired drug resistance are being increasingly reported in Africa, Asia, and Latin America.   Also, while this disturbing rise in drug resistance seems largely restricted to developing nations, at least for now, the rise in new cases will almost certainly spread to developed nations as they did during the first wave of AIDS deaths.  

As health experts warn, it is far too soon to assume the war against HIV/AIDS is over, especially with these new challenges being faced.  How we deal with this new epidemic in the making may be our most crucial test yet.

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Sexual Discounting and High-Risk Behaviour

Youth under 25 show substantial sexual and substance use risk behaviors. One factor associated with risk behaviors is delay discounting, the devaluation of delayed outcomes. A study published in Experimental and Clinical Psychopharmacology determined if delay discounting for sexual outcomes is related to sexual risk and substance use among 18–24 year olds. Females (70) and males (56) completed the Sexual Discounting Task, which assessed their likelihood of having unprotected immediate sex versus waiting for sex with a condom, at various delays, with 4 hypothetical sexual partners selected from photographs: the person they most wanted to have sex with, least wanted to have sex with, judged most likely to have a sexually transmitted infection (STI), and judged least likely to have an STI. They also completed instruments assessing HIV knowledge, sexual behaviors, substance use, risk attitudes, inhibition, impulsivity, and sensation-seeking. Condom use likelihood generally decreased with increasing delay. Preference for immediate, unprotected sex was greater for partners whom participants most (vs. least) wanted to have sex with and judged least (vs. most) likely to have an STI. Preference for immediate, unprotected sex in the “most want to have sex with” and “least likely to have an STI” conditions was related to greater lifetime risky sexual partners, lifetime number of unique substances used, disregard of social approval/danger, disinhibition, and sensation/excitement-seeking. Males showed greater likelihood of unprotected sex than females when condom use was undelayed, but delay similarly affected condom use between sexes. Delay discounting should be considered in strategies to minimize youth risk behavior.

For the abstract

Canadian Supreme Court Decision Welcomed by Safe Injection Site Advocates

In a move that Canadian Prime Minister Stephen Harper described as "disappointing", the Canadian Supreme Court has ruled that attempts by the Federal government to shut down Insite, Canada's only safe injection site, violates Canada's Charter of Rights and Freedom.  Writing on behalf of her eight colleagues, Chief Justice Beverly McLachlin has stated that "Insite is effective in reducing the risk of death and disease, and has no negative impact on the legitimate criminal law objectives of the federal government".    Jutice McLachlin further added that failure to allow Insite to remain open would threaten the health of those injection drug users depending on medical services provided at the facility and actually undermine the purpose of the federal drug law, which includes public health as one of its mandates.  The ruling upholds a 2008 decision by British Colombia's Supreme Court in allowing Insite to continue operating in Vancouver's downtown core.  Still,  the Supreme Court stressed that their decision "is not a licence for injection drug users to possess drugs wherever and whenever they wish. Nor is it an invitation for anyone who so chooses to open a facility for drug use under the banner of a 'safe injection facility'".  

First opened in 2003, , Insite is North America's first legal supervised injection site based on a harm reduction model for minimizing the health risks associated with unsafe drug use.   By providing Vancouver's downtown addicts with a safe site for injecting drugs,  harm reduction advocates have stressed the importance of helping addicts avoid diseases such as hepatitis and AIDS.   While operating under a special exemption to federal drug legislation, the safe injection site has long been a target of conservative critics and the Federal government which has threatened staff and patrons with prosecution.  

News of the decision was greeted with wild celebration by hundreds of supporters who were gathered outside the facility.  Cheers, hugging, and horn honks by vehicles passing by outside the Hastings Street location erupted after the ruling was announced at 7 am, PST.   Despite his own stated opposition, Prime Minister Harper has stated that the Federal government will comply with the ruling.   Although research has consistently shown the health benefits of safe injection sites such as Insite,  conservative opposition groups have opposed their opening in other North American cities.   In agreeing to accept the Supreme Court ruling, Prime Minister Harper has refused to speculate on the possibility of similar safe sites being established across the country. 

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New Approach Needed To Address National 'Epidemic Of Mass Incarceration'

In an article scheduled for release in the June 2 issue of the New England Journal of Medicine, researchers from Brown University's Center of Prisoner Health and Human Rights state that the United States is dealing with an "epidemic of mass incarceration".    According to Josiah D. Rich, M.D., M.P.H.,  who is co-director of the Center as well as a professor of medicine at Brown University,  many of the 2.3 million Americans who are behind bars and the estimated 10 million who cycle in and out of prison each year suffer from substance abuse and mental illness.  The inadequate treatment options in most communities has been exacerbated by the severe policy changes of the past 30 years which has been linked to the ongoing "War on Drugs".  Dr. Rich stresses that "More than half of all inmates have a history of substance use and dependence or mental illness, yet they are often released to the community without health insurance or access to appropriate medical care and treatment.  Sadly, without these linkages to transitional care in the community, the majority of these individuals will re-enter the revolving door of the criminal justice system, which already costs our county $50 billion annually."

According to Dr. Rich and his co-authors, Sarah E. Wakeman, M.D., of Massachusetts General Hospital, and Samuel L. Dickman, A.B., of Harvard Medical School, incarceration has risen by 600 per cent over the last 40 years.    With an estimated 1 in 100 Americans currently incarcerated, no other country comes close to the United States in terms of incarceration rate.  Given that most Americans in prison come from low-income and minority populations,  racial and socioeconomic disparities in availability of health care risk being perpetuated indefinitely.     Psychiatric problems in prisoners remain a special concern since major depression and psychotic disorders are four to eight times as prevalent as in the general population.    Only 22 per cent of state prisoners and 7 per cent of jail inmates receive any form of mental health care while incarcerated.

With the growing number of substance abusers in prisons, the prevalence of infectious disease among inmates has also increased dramatically.  An estimated 25 per cent of all HIV-positive Americans and a third of all individuals with Hepatitis C pass through the criminal justice system each year.  Other chronic illnesses that are overrepresented in prison populations include hypertension and diabetes.  The cost of care is expected to rise in coming decades as dementia becomes more prevalent among prisoners due to increased incidence of Alzheimer's disease, AIDS-related dementia, and similar illnesses.

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"Civil Disobedience" Threatened Over Closure of Supervised Injection Site

Community activists in Vancouver's downtown have threatened "civil disobedience" to protest the impending closure of a controversial supervised injection site for drug users.   First opened in 2003, Insite is North America's first legal supervised injection site based on a harm reduction model for minimizing the health risks associated with unsafe drug use.  Funded by British Columbia's Ministry of Health Services and Health Canada, Insite has functioned under a special exemption to the Federal Controlled Drug and Substances Act.   Although the exemption has been renewed several times since 2006, the Federal governmen has threatened to close the centre and a constitutional challenge is currently underway.

Harm reduction refers to public policies designed to decriminalize recreational drug use and provide substance abusers with safe avenues for minimizing diseases such as hepatitis and HIV.  Harm avoidance strategies, including the use of needle exchange programs and safe injection sites, represent a controversial alternative to more conventional approaches such as criminal convictions for drug possession and forced abstinence.  Safe injection site programs have been used successfully in a number of European countries since 1986. 

The Insite program is designed to provide drug users with a safe, health-focused site for injected drug use (primarily heroin, cocaine, and morphine).    The downtown Vancouver location was selected given the acute injected-drug epidemic occuring in that area.  On-site medical staff provide drug users with substance abuse counseling, medical advice, and first aid in the event of overdoses or injuries.  In 2009 alone, the site recorded 276,178 visits by 5,447 unique users.    The program enjoys overwhelming support in the Vancouver area.

When the Insite program first opened in 2003, it was  granted a three-year exemption from federal drug legislation given its experimental nature.  Although the program was initially intended to be closed in 2006, the Conservative minority government granted several extensions but has refused to extend them further.   Insite has faced continued opposition from Canada's Conservative minority government despite research showing that the site has led to a 35% drop in overdose death in the area served (as opposed to a 9% increase in other parts of Vancouver).   Despite the expenses associated with running Insite, cost-benefit analyses have consistently shown the benefits of continuing the program.   Although the Federal government has commissioned research studies that refute the harm avoidance model, critics have condemned the research as being flawed.

While the Supreme Court of British Columbia has ruled that Insite should be continued, the Federal government has been fighting the decision and has announced plans to appeal to the Supreme Court of Canada.  Protests and demonstrations over the threatened closure of Insite have become a common sight on the streets of Vancouver in recent months.   Given the Conservative government's stated intentions (and the majority they received in the recent federal election), the protests are likely to continue.

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